Not all mothers-to-be know what they can do to ensure they have a healthy pregnancy but community pharmacists are well placed to advise and educate them, as Steve Titmarsh explains…

A pilot study looking at the impact of pharmacy-based interventions on maternal and infant health in pregnancy, the perinatal period and early years found gaps in women’s knowledge of healthcare in pregnancy. For example:

• 31 per cent were unaware of the importance of oral health checks
• 24 per cent were unaware of the importance of early booking for antenatal clinic
• 22 per cent did not know about maternal immunisations
• 16 per cent did not know about the importance of a healthy lifestyle
• 7 per cent were unaware of the importance of taking folic acid and vitamin D during pregnancy.

Health information is important for pregnant women: it increases the ability to adopt preventive behaviours; increases their ability to look after themselves and reduces anxiety about new health issues or stressful situations.¹ A woman’s health at the time of conception has important consequences for the health of her child for the rest of their lives.²

The National Institute for Health and Care Excellence provides guidance on routine antenatal care, including at the first antenatal (booking) appointment, and later if appropriate, information about nutrition and diet, physical activity, smoking cessation and recreational drug use.³

Antenatal appointments should be booked as soon as possible after a woman knows she is pregnant so she can receive timely advice about a healthy pregnancy. The first appointment with a midwife or GP should happen between weeks 8 and 10 of pregnancy. But women should contact their GP or midwife as soon as they know they are pregnant so they can find out about folic acid supplements; nutrition, diet and food hygiene; lifestyle factors – such as smoking, drinking and recreational drug use, and antenatal screening tests.⁴

A study among Dutch women found that 8 out of 10 found professional information sources trustworthy and useful, while digital sources were perceived as less trustworthy and useful. Nevertheless, digital sources were widely used: the most commonly used information sources were midwives (91.5%), family or friends (79.3%), websites (77.9%), and apps (61%). The authors comment that professionals need to help in the development of digital information sources to meet the needs of today’s pregnant women.⁵

Formal evidence suggests that community pharmacists can improve women’s health before and during pregnancy, particularly regarding smoking cessation and taking folic acid.⁶

Supplements

Women need to know that it is important to take 400microgram of folic acid every day before they are pregnant, if they are planning to become pregnant and to continue until the 12th week of pregnancy. Some women at higher risk of birth defects will need to take 5mg of folic acid daily until the 12^th week of pregnancy. Those at higher risk include:⁷

• Mothers or babies whose biological father has a neural tube defect or has a family history of neural tube defects
• Mothers who have had a previous pregnancy affected by a neural tube defect
• Mothers with diabetes
• Mothers who take anti-epilepsy medicine
• Mothers who take antiretroviral medicine for HIV.

Folic acid can help prevent birth defects – neural tube defects – including spina bifida. Green leafy vegetables contain folate (the natural form of folic acid), and breakfast cereals and fat spreads may have folic acid added to them. However, most diets will not provide the amount of folate recommended for a healthy pregnancy, which is why it is important for women to take a folic acid supplement.⁷

Women also need 10microgram of vitamin D each day while they are pregnant and breastfeeding. Vitamin D is made by the body when the skin is exposed to sunlight. It is also found in some foods, including:⁷

• oily fish (eg salmon, mackerel, herring and sardines)
• eggs
• red meat.

Vitamin D is also added to some breakfast cereals, fat spreads and non-dairy milk alternatives but in varying amounts.⁷ Again, it may be difficult to obtain the recommended daily amount from the diet and not enough is produced by the skin from September to March in the UK when sunlight hours are reduced. So that is the time to consider taking a daily supplement.⁷

People with dark skin or those who cover their skin as protection from the sun when outdoors are also at risk of not having enough vitamin D and may need to take a supplement year-round. ⁷

Rachel Anthony, a spokesperson for BlueIron, says the “pregnancy journey brings with it a whole host of changes.”

“As you navigate the diverse landscape of pregnancy-related conditions, it's essential to recognise the pivotal role of iron when maintaining not just your health, but your baby’s too,” she says.

“When pregnant, a woman’s blood volume increases by almost 50 per cent. But, sometimes during this stage, a lack of red blood cells can result in low iron which can lead to reduced energy and fatigue, especially if you’re having twins.”

Dental health

Pregnancy gingivitis, where gums become swollen, red and tender, and may bleed when teeth are brushed or flossed, is thought to be related to progesterone levels, which lead to increased blood supply to the mouth rendering gums more vulnerable to bacteria. Brushing teeth twice a day for two minutes each time using a toothpaste containing 1000–1500 parts per million of fluoride helps keep the mouth healthy. Advise women to spit toothpaste out when they have finished brushing but not to rinse. If gums continue to bleed women should be advised to consult their dentist or hygienist.⁸ Eating more nutritious snacks containing less sugar, such as raw fruit, vegetables, yogurt or cheese and drinking water or low-fat milk, can be beneficial.⁹

Pregnant women should be advised to avoid brushing their teeth for at least an hour after morning sickness, and chewing gum containing xylitol during pregnancy can help reduce the amount of cariogenic Streptococcus mutans in the mouth. Xylitol may also help prevent transmission of harmful bacteria to infants with beneficial effects for their own dental health.¹⁰

Vaccinations

Pregnant women are advised to have vaccinations against flu, whooping cough and COVID-19 to protect themselves and their babies. Live vaccines such as BCG, MMR and yellow fever are not generally recommended during pregnancy unless advised by a GP.¹¹

Whooping cough vaccine is recommended from week 16 of pregnancy while flu and COVID-19 vaccines should be given during the winter vaccine/flu season from September to March at any stage of pregnancy.¹²

Products to support mother and baby

Community pharmacies can not only offer pregnant women help and advice during their pregnancy and the important months following the birth of their babies, but they can also provide a wide range of useful products to help keep mother and baby healthy, including:

• Oral hygiene products
• Dietary supplements
• Pregnancy tests
• Nappies
• Nappy rash cream / barrier cream
• Baby wipes
• Formula milk
• Feeding bottles
• Sterilising equipment

References

1. Javanmardi M, Noroozi M, Mostafavi F, et al. Exploring Women’s Health Information Needs During Pregnancy: A Qualitative Study. J Fam Reprod Health 2020;14(4):252–8.
2. McDougall B, Kavanagh K, Stephenson J, et al. Health behaviours in 131,182 UK women planning pregnancy. BMC Pregnancy Childbirth 2021;21:530.
3. National Institute for Health and Care Excellence. Antenatal care. NICE guideline [NG201] (www.nice.org.uk/guidance/ng201; accessed March 2024).
4. NHS.UK. Your antenatal appointments (www.nhs.uk/pregnancy/your-pregnancy-care/your-antenatal-appointments; accessed March 2024).
5. Vogels-Broeke M, Daemers D, Budé L, et al. Sources of information used by women during pregnancy and the perceived quality. BMC Pregnancy Childbirth 2022;22:109.
6. Scott PA, Quotah OF, Dalrymple KV, et al. Community Pharmacist-Led Interventions to Improve Preconception and Pregnancy Health: A Systematic Review. Pharmacy (Basel) 2021;9(4):171.
7. NHS.UK. Vitamins, supplements and nutrition in pregnancy (www.nhs.uk/pregnancy/keeping-well/vitamins-supplements-and-nutrition; accessed March 2024).
8. NHS Inform. Looking after your teeth and gums in pregnancy (www.nhsinform.scot/ready-steady-baby/pregnancy/looking-after-yourself-and-your-baby/looking-after-your-teeth-and-gums-in-pregnancy; accessed March 2024).
9. nct. Five tips for looking after your teeth when you’re pregnant (www.nct.org.uk/pregnancy/who-will-care-for-you-during-pregnancy/five-tips-for-looking-after-your-teeth-when-youre-pregnant; accessed March 2024).
10. Dentistry. Why we must prioritise the dental health of pregnant mothers now more than ever (https://dentistry.co.uk/2020/10/08/prioritise-dental-health-pregnant-mothers; accessed March 2024).
11. NHS.UK. Vaccinations in pregnancy (www.nhs.uk/pregnancy/keeping-well/vaccinations/#:~:text=Some%20vaccines%2C%20such%20as%20the,virus%20it%20is%20protecting%20against; accessed March 2024).
12. NHS inform. Vaccines in pregnancy (www.nhsinform.scot/ready-steady-baby/pregnancy/your-antenatal-care/vaccines-in-pregnancy; accessed March 2024).
13. Public Health Agency. The Pregnancy Book 2023 (www.publichealth.hscni.net/publications/pregnancy-book-0; accessed March 2024).